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APPLICATION FOR SANITATION PERMIT Permit No. -------------- (Complete _-----_(Complete in Duplicate) Date Issued Application is�ereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatior0is made in c ifmpliance with County Ordinanc No. 549. k JOB ADDRESS AND L CAT NUJ_ _ - C/il ` Owner's Name-------------- -- -- --- -} --------- Phone------------------------------------ Address------------------------------------- �� ` . / ------------------------------------•----------------------------•--------- iI Contractor's Name--------.. .. Phone. Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other ❑ I IM °� ` -------------- Number of living units: __�.__ Number of bedrooms _/2_ Number of baths __/__ Lot size ___-_____ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _ - ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ ,.Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ i Previous Application Made: aYes ❑ No 'New Construction: Yes ❑ No ®/FFAA/VA; Yes ❑ No [t].r--- I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) peptic anh: Distance from nearest well_________________Distance from foundation--------------------Material----------------- .________________..________._. � No. of compartments--------------------------Size--_---------------------:---Liquid depth ------------------------Capacity----------------------- Dis o I Field: - Distance.from nearest weli__rkoxC:._`Distance from foundation___-. --------Distance to nearest lot line___-�_�___. Length of each line---__ -- _ _ -----.Width of trench------ -r--------------- p Number,�of lines---------- f------�� i \l k, Type of` Iter material-_/ff__. _. __Depth of filter materia l___1 � --�-_Total length__---_---- �________________`___ Q.__ .Distance to nearest lot ine,__ ------ Seepage Pit: Distance to nearest well_.`'j�$vL _--Distance fr m f ndation___. ta c , ----Linin material---- _____.�____ _.Size:-0iameter-----------__------Depth--.-------- - -------------- Numberlof pits_____--------- g Cesspool: Distance from nearest well_______________ Distance from foundation--------------------Lining material_-_______.__________---_____________- II Liquid Capacit gals. ❑ Size:,Diamefer-- - ---------- ---------------De Dept - Y Privy: Distance from nearest well--------------------- -------------------w------Distance from nearest building------_---------------------------------- ❑ Distancel to nearest lot 4ine---------------------------------------------- ------------- ------------------------------------------------------ N 4��--- 'r --------------------------------------------- Remodeling and/or repairs Ig �dascribeJ___________________________ _ --•------------------------- ---------------------------------------------------------------------------------------------------------- -------------------------•-----•---------------------------------- ---------------- --------=------------------------------------------------------------------- ----------------------------------------- ------------- ---------------------------•-------------------- --------------------•------------------------------------------------------------------------- = I hereby certify that I have prepared this application and tha+ the-work will be done in accordance with San Joaquin County ordinances, State laws, andl:�rules a d regulations of the San Joaquin Local Health District. 1� — ---------(Owner and/or Contractor S� ned ----------- Title------------ --- ------------- -----------------------I ---------------------------------- { ) (Plot plan, showing size of 14, location of system ' .relation to wells, buildings, etc., can be placed on reverse side). I� FOR DEPARTMENT USE ONLY. APPLICATIONACCEPTEDI WY --------------------------------------------------------------------------------------•---- DATE zz-------------------- --------------------------------- REVIEWED BY------- ISSUE--�,----------: — -------=--------------------- -----------------------------------I --------------------- DATE__.' --- --------------------- - -� ----------------- BUILDING PERMIT D ----- - � -------------- --------------------------------- -° ------------------------------ DATE------ 7 ----------------------------------------------- Alterationsand/or recommendations------------------------------ ---------------- ------------------------------------ ------------------ •------------------------------------------------------ f ___ _ -------------- 5- -------------------------------------- --------------- ------ _'.. - - - ----- ' - -- --- - ----- Ir FINAL INSPECTION BY'M------ Date---- -- ---------------- -------------------------- SAR JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West {{Jak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, Cdlifornia Manteca, California Tracy, California ES 9--21 Revised I.57 F.P.CO. fi _